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Medical
Record Review Protocol
Medicare
General
Documentation Requirements
in Teaching Settings
E/M
Documentation Provided
by Medical Students
E/M
Services – General
Information for
Teaching Physicians
E/M
Service – Scenario
1 (TP performs all
elements without
a resident.)
E/M
Service – Scenario
2 (TP performs elements
jointly with a resident.)
E/M
Service – Scenario
3 (TP follows resident
in performing service.)
Primary
Care Exception Services
Surgery,
Including High-Risk
and Complex Procedures
Minor
Surgery
Endoscopy
Procedures
Pre-operative
and Post-operative
care
Co-Surgeons
(Surgical, High
Risk and Complex
Procedures)
Assistant
at Surgery
Anesthesia
Interpretation
of Diagnostic Radiology
and Other Diagnostic
Tests
Maternity
Time-Based
Medical Services
(prolonged services,
care plan oversight)
Critical
Care Services
Psychotherapy
Services
Ophthalmological
Services
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